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ALL INDIA RBI OERS PENSIONERS FORUM.

Group MEDICLAIM Policy For Retired Members of Medical Assistance Fund Scheme(MAFS)

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Expenses not connected with the treatment and cost of non-medical items which are not presently covered under MAFS will be excluded from the Policy.

Pathological tests and other tests undergone by the members that do not lead to any medically justified hospitalisation are not reimbursed under MAFS.The same rules will apply under the Policy.

The Policy will not cover treatment taken abroad.

In case the members have their own individual mediclaim policies and they prefer to claim first under their Policy, the balance amount can then be claimed under the Bank's Policy. Alternatively, they can first claim from the TPA under the Bank's Policy and then the balance amount under their own Policy.

TPAs will issue an identity card to the members which along with the MAF card issued by the Bank will be required for identification at the time of hospitalisation.
In case of cashless facility, any expenditure incurred over and above the prescribed limit per hospitalisation will have to be settled with the hospital by the member.
In case of any dispute over settlement of claims between the TPA / Insurance Company and the members, the Bank will be the final authority to decide the issue.
Other benefits available under MAFS like dispensary facility/annual health checkup will continue to be administered by the Bank as hitherto.
The Bank has setup a help desk in each office to assist/guide the retired members. The TPAs can also be directly contacted by the members in case of need.

Salient Features of Mediclaim Policy for retired members of MAFS

Group Mediclaim Policy (hereafter Policy) covers hospitalisation expenditure of retired members of MAFS for self and spouse.

The Policy is effective from August 15, 2007.
The Policy will be administered by a Third Party Administrator (TPA). There are three TPAs at present. Regional Offices and Central Office Departments are allotted among the three TPAs.
Each TPA has a state wise list of network hospitals, (available with help desk and website of respective TPAs).
Hospitalisation facility on cashless basis can be availed anywhere in the country through the network hospitals of the respective TPAs.
In case of planned hospitalisation to a network hospital cashless facility will be available on giving prior intimation to the TPA, while in case of emergency, cashless facility can be availed on giving intimation to TPA within the shortest time possible.
In case of hospitalisation to a non-network hospital, as also claims for pre & posthospitalisation, it will be settled by the TPA on reimbursement basis on submission of bills / documents in original to them without delay but not later than 30 days of discharge / completion of post hospitalisation treatment.
In case of treatment in Government Hospitals / Institutes where cashless facility is not available, TPAs will extend the facility of advance payment up to certain percentage of estimated cost of treatment within the overall entitlement of the member.
The member may have to make a token deposit (refundable), in case of emergency / planned hospitalisation, if the hospital insists on such payment to cover non-medical expenses, if any.
The hospitalisation bills will be settled within the existing grade wise overall monetary ceiling and indicative limit for bed charges. There would be no classification of operations such as minor, less major, major, major plus and super major. All other sub-limits/schedules for treatment during hospitalisation have been dispensed with.
Pre-hospitalisation expenses up to 30 days and post-hospitalisation expenses up to 60 days are covered within the ceiling.
A number of day care procedures (list available with help desk) which do not require 24 hours hospitalisation have been included in the policy.
In case of death of a member / spouse covered under the Policy, the entire hospitalisation expenditure will be paid without any ceiling.
Pathological tests and other tests undergone by the members that do not lead to any medically justified hospitalisation are not reimbursed under MAFS. The same rules will apply under the Policy.
The Policy will not cover treatment taken abroad.